Correspondence

What Transplantation Can Teach Us about Health Care Reform

N Engl J Med 1994; 331:813September 22, 1994

Article

To the Editor:

Benjamin et al. (March 24 issue)1 assert that the allocation of organs for transplantation follows rational principles that are embraced and applied ubiquitously -- in fact, legislated at the federal level. They further believe that “when the community devises defensible principles for the allocation of limited public resources, we all have a duty as citizens to cooperate.” This implies a sense of order in access to organ transplantation that, in truth, does not reflect the reality.

Before any patient is placed on a waiting list for an organ, he or she is subject to an intensive review of appropriateness. Each transplantation program has adopted a set of guidelines that is used by a multidisciplinary screening committee to complete that review. Candidates for the waiting list are presented to the committee and assessed on the basis of the guidelines. Psychological factors, the availability of family resources, financial status, health insurance, and personal health habits are among the nondiagnostic factors that are reviewed. The simple fact that these reviews are hospital-dependent and quite idiosyncratic makes the subsequent rationalization of organ allocation much less meaningful. The peculiarities of this screening process allow insured alcoholics to receive liver transplants while poor patients with cardiomyopathy are left to their own devices.

A second vexing problem is the geographic distribution of transplantation centers. Despite the clear advantages of maintaining a minimal number of sites carefully selected on the basis of community needs and clinical expertise, hospitals feverishly jockey to perform transplantation for the status and market prestige that it brings. Thus, the current transplantation system lacks the quality and cost advantages that a concentrated volume could bring to it.

Perhaps it would have been more illuminating if the Michigan ethics panel had analyzed how current barriers to tertiary care might serve as a guide in the drafting of our health care reform policies. Rather than a model of rationality, the current system of transplantation is a reflection of our current health care plight.

Jeffrey Otten
Brigham and Women's Hospital, Boston, MA 02115

1 References

1. 1

   Benjamin M, Cohen C, Grochowski E. What transplantation can teach us about health care reform. N Engl J Med 1994;330:858-860
   Full Text | Web of Science | Medline

Author/Editor Response

Dr. Benjamin replies:

To the Editor: Mr. Otten identifies two shortcomings of the current practice of organ allocation. From these he concludes that we are out of touch with reality in suggesting that the transplantation system can serve as a model for some aspects of health care reform. His reasoning, however, is invalid.

Nowhere in our essay do we claim that the transplantation system is perfectly just. On the contrary, we frankly acknowledge several possible abuses and remaining difficulties. But these shortcomings, together with those identified by Mr. Otten, do not discredit the overall justice of the allocation system, especially if we compare current practice with the arbitrariness and favoritism endemic to organ allocation before the implementation of the national network.

Those who developed this network had to overcome many of the same obstacles that now stand in the way of reforming the health care system as a whole. That these problems could, for the most part, be justly resolved in the limited domain of transplantation suggests that they may eventually be overcome in the more daunting task of reforming the overall system. This is so even if, as Mr. Otten points out, there is more to be done in improving the justice and efficiency of organ allocation.

Martin Benjamin, Ph.D.
Michigan State University, East Lansing, MI 48824-1032